COMBINED (P.G.

) INSTITUTE OF MEDICAL SCIENCES &

RESEARCH
DEHRADUN, UTTARAKHAND

Medical Surgical Nursing

Assignment
On
Central Venous Access Catheter Insertion, assisting

Submitted To Submitted By
Mohamad Dildar
M.Sc Nursing 1st Year

Submitted On
 Central venous access catheter insertion, assisting

Introduction

A central venous access catheter is a sterile catheter that's inserted through a large vein to provide access
to the central veins. The catheter is made of polyurethane or silicone rubber. Catheters impregnated with antiseptics
(such as chlorhexidine) or antimicrobials (such as silver, carbon, platinum, minocycline, and rifampin) are
recommended for patients in hospital units or patient populations with vascular catheter–associated infection rates
that are higher than facility goals even after other vascular catheter–associated infection practices have been
implemented; patients with limited venous access or a history of vascular catheter–associated infection; and in
individuals with an increased risk of complications from a vascular catheter–associated infection, such as patients
with implanted IV devices. 1 Collaborate with the interprofessional team to consider the use of an anti-infective
catheter. Don't use anti-infective catheters in patients with allergies to the anti-infective substances. 2 Power
injectable catheters are also available to enable power injection of contrast media in patients who require computed
tomography and other testing.

A practitioner inserts a central venous catheter through a large vein, such as the subclavian or internal jugular vein,
and places the tip of the catheter in the superior vena cava. (See Central venous access catheter pathways.)

By providing access to the central veins, a central venous catheter offers several benefits. It allows monitoring of
central venous pressure, which indicates blood volume or pump efficiency, and permits aspiration of blood samples
for diagnostic tests. It also allows for the administration of IV fluids (in large amounts if necessary) in emergencies,
when decreased peripheral circulation makes peripheral vein access difficult, when prolonged IV therapy reduces the
number of accessible peripheral veins, when solutions must be diluted (for large fluid volumes or irritating or
hypertonic fluids such as total parenteral nutrition solutions), and when a patient requires long-term venous access.
Because multiple blood samples can be drawn through it without repeated venipuncture, a central venous access
catheter also decreases patient anxiety and preserves the peripheral veins.

Central venous access therapy increases the risk of such complications as pneumothorax, vascular catheter–
associated infection, sepsis, thrombus formation, and vessel and adjacent organ perforation (all life-threatening
conditions). Because of age-related changes in the immune system, older adults are more susceptible to infection
than younger adults. Remote infections may also increase the risk of vascular catheter–associated infections in older
adults. 3

Hospital-acquired condition alert: A vascular catheter–associated infection is considered a hospital-acquired

condition because it can be reasonably prevented using best practices. Make sure that infection prevention
techniques (such as properly preparing the intended insertion site, using an all-inclusive insertion kit, using an
insertion checklist, and instituting maximal barrier precautions) are followed during insertion to reduce the risk of
vascular catheter–associated infection; stop the procedure for any breach in sterile technique that

occurs.1 4 5 6 7

CENTRAL VENOUS ACCESS CATHETER PATHWAYS

The illustrations below show two common pathways for central venous access catheter insertion. Typically,
a central venous access catheter is inserted in the subclavian or internal jugular vein and terminates in the superior
vena cava. The subclavian site is preferred over the internal jugular site in adults to reduce the risk of infection; 8 9 10
however, in patients with advanced kidney disease and in those receiving hemodialysis, the subclavian site should be
avoided to prevent subclavian vein stenosis. 8 10 If the patient has a pacemaker in place, he should be assessed
carefully to determine the most appropriate catheter and insertion site. Pacemakers commonly are inserted on the
left side of the chest or abdomen, so the contralateral side is preferred for central venous access catheter placement.
If the ipsilateral side is preferred, a peripherally inserted central catheter may be the safest option. 11
Insertion: Subclavian vein

Termination: Superior vena cava

Insertion: Internal jugular vein

Termination: Superior vena cava

Equipment

 Facility-approved disinfectant

 Insertion checklist

 Sterile gloves

 Sterile gowns

 Caps

 Masks

 Blanket

 Fluid-impermeable pad

 Large sterile drape Antiseptic solution (chlorhexidine-based preferred; tincture of iodine, povidone-iodine, or
alcohol if chlorhexidine is contraindicated)

 Alcohol pads

 10-mL pre-filled syringes containing preservative-free normal saline solutionUltrasound device with sterile
probe cover
  Sterile ultrasound gel

 3-mL syringe with 25G 1" (2.5 cm) needle

 1% or 2% injectable lidocaine

 Engineered stabilization device

 Two central venous access catheters (antimicrobial impregnated if indicated)

 IV solution with administration set

 Electronic infusion device (preferably a smart pump with dose-error reduction software) Sterile needleless

 connectors (for each catheter lumen)

 Sterile marker

 Sterile labels

 Transparent semipermeable dressing

 Sign

 Pulse oximeter and probe

 Cardiac monitoring equipment

Optional: skin preparation kit, disposable-head surgical clippers or single-patient-use scissors, sterile towel, antiseptic
soap, water, prescribed sedative or analgesic, suture material, suture kit (sterile scissors, hemostat, and needle
holder), disinfectant-containing end caps

GUIDE TO CENTRAL VENOUS ACCESS CATHETERS

 1. Short-term single-lumzen catheter

Description

Polyurethane or silicone rubber (Silastic) About 8" (20.5 cm) long

Lumen gauge varies
Percutaneously placed

Indications

Short-term central venous (CV) access Emergency access

Patient who needs only one lumen

Advantages

Easily inserted at bedside

Easily removed
Stiffness aids CV pressure monitoring

Disadvantages
Limited functions

Nursing considerations

Assess frequently for signs of infection and catheter patency.

During dressing changes, assess the external length of the catheter to detect catheter migration.

2. Short-term multilumen catheter

Description

Polyurethane or silicone rubber

Two, three, or four lumens exiting at 3⁄4" (2-cm) intervals Lumen gauges vary
Percutaneously placed

Indications

Short-term CV access
Patient with limited insertion sites who requires multiple infusions

Advantages

Easily inserted at bedside

Easily removed
Stiffness aids CV pressure monitoring
Allows infusion of multiple (even incompatible) solutions through the same catheter

Disadvantages
Limited functions

Nursing considerations

Know the gauge and purpose of each lumen.

During dressing changes, assess the external length of the catheter to detect catheter migration.

3. Short-term power injectable catheter

Description

Polyurethane and other materials One, two, or three lumens Various lumen gauges Percutaneously placed

Indications

Short-term CV access
Patient who requires contrast media for testing

Patient with limited insertion sites who requires IV fluids, blood products, parenteral nutrition, blood withdrawal, or
CV pressure monitoring

Advantages

Allows power injection of contrast media Easily inserted at bedside

Easily removed

Disadvantages None

Nursing considerations

Don't use a syringe smaller than 10 mL to flush the device.

During dressing changes, assess the external length of the catheter to detect catheter migration.

Preparation of Equipment
 1. Before insertion of a central venous access catheter, confirm catheter type and size with the practitioner; a
14G or 16G catheter is typical. Also confirm whether the practitioner intends to use ultrasound to guide
insertion. If so, obtain the equipment and make sure it's functioning properly.

2. Inspect all IV equipment and supplies; if a product is expired, its integrity is compromised, or it's found
defective, remove it from patient use, label it as expired or defective, and report the expiration or defect as
directed by your facility. 12

3. Perform hand hygiene to prevent the spread of microorganisms. 8 13 14 15 16 17 18 19 20 Set up the IV solution
and prime the administration set using strict sterile technique. 11 Attach the primed IV administration set to
the electronic infusion device.

4.
Recheck all connections to make sure they're tight to prevent dangerous disconnections. 21

Implementation

o Verify the practitioner's order.

o Confirm that the practitioner has obtained written informed consent and that the consent form is in the
patient'smedicalrecord.22 23 24 25 26

o Reinforce the practitioner's explanation of the procedure, and answer the patient's questions. Check his
history for hypersensitivity to latex or the local anesthetic.

o Gather and prepare the necessary equipment. Performhandhygiene.8 13 14 15 16 17 18 19 20

27
Confirm the patient's identity using at least two patient identifiers. Provideprivacy.28 29 30 31

o Provide the patient with information that addresses the rationale for device insertion, the insertion process,
expected dwell time, care and maintenance of the device, and signs and symptoms of complications that
32
should be reported.

o Conduct a preprocedure verification to make sure that all relevant documentation, related information, and
equipmentareavailableandcorrectlyidentifiedwiththepatient'sidentifiers. 33 34

o Close the door to the room and place a sign on the door that reads, "sterile procedure in progress—do not
enter."3 35

o Raise the bed to waist level when providing care to prevent caregiver back strain. 36

o Attach the patient to a cardiac monitor and pulse oximeter. 37

Make sure that alarm limits are set
appropriately for the patient's current condition and that alarms are turned on, functioning properly, and
audibletostaff.38 39 40 41

o Obtain the patient's vital signs and oxygen saturation level using pulse oximetry to serve as a baseline for
37
comparison during and after the procedure.
o If ultrasound is available, assist the practitioner to evaluate the patient's vasculature to determine the
35
insertion site.

o Administer a sedative or an analgesic, if ordered, following safe medication administration practices. 37 42 43

44 45

o Put on a cap and a mask.3 35 Performhandhygiene.8 13 14 15 16 17 18 19 20

o Disinfect the work area (such as an overbed table) with a facility-approved disinfectant and allow it to dry
completely.3 35

o Place the patient in the Trendelenburg position to dilate the veins and to reduce the risk of air embolism.

o For subclavian vein insertion, place a rolled blanket lengthwise between the patient's shoulders to increase
venous distention. For jugular vein insertion, place a rolled blanket under the opposite shoulder to extend
the patient's neck, making anatomic landmarks more visible.

o Place a fluid-impermeable pad under the patient to prevent the bed from becoming soiled.

o Use an insertion checklist as per the hospital's policy to help comply with infection prevention and safety
practices during insertion. 1 5 8 11 46 (See Sample central venous access catheter insertion checklist.) Stop
the procedure immediately if you observe any break in sterile technique.

o Turn the patient's head away from the site to prevent possible contamination from airborne pathogens and
37
to make the site more accessible.

o Prepare the insertion site:

o Remove excess hair from the intended insertion site, if needed, using a single-patient-use scissors or
11
disposable-head surgical clippers to facilitate dressing application.

o Iftheintendedsiteisvisiblysoiled,cleantheareawithantisepticsoapandwater. 3 11 35 Performhandhygiene.8 13 14 15
16 17 18 19 20

o Establish a sterile field on a table using a sterile towel or the wrapping from the instrument tray and
assemblesuppliesonthesterilefield.3 35

o Labelallmedications,medicationcontainers,andothersolutionsonandoffthesterilefield. 47 48 49

o Performhandhygiene.8 13 14 15 16 17 18 19 20

o Putonasterilegownandsterileglovestocomplywithmaximalbarrierprecautions. 1 8 11 50 51
o Before beginning the procedure, the practitioner will put on a mask, a cap, and a sterile gown and gloves to
complywithmaximalbarrierprecautions.1 8 11 50 51

o Assist the practitioner as needed to prepare the insertion site. He'll clean the site with a chlorhexidine
8 9 11 52
sponge using a vigorous side-to-side motion for 30 seconds and then allow the area to air
8 11 35
dry. If povidone-iodine solution is used, he'll apply it using swabs, beginning at the intended insertion
site and moving outward in concentric circles. The solution should remain on the skin for at least 2
minutesuntilitdriescompletely.3 11 35

o Removeanddiscardyourgloves.(Thepractitioneralsoremovesanddiscardshisgloves.) 50 51 53

o Performhandhygiene.(Thepractitioneralsoperformshandhygiene.) 5 13 14 15 16 18 19 20

o Putonsterilegloves.(Thepractitioneralsoputsonsterilegloves.) 50 51 54

o The practitioner drapes the patient with a large full-body sterile drape to create a sterile field and to comply
withmaximalbarrierprecautions.1 8 11 52

o Conduct a time-out immediately before starting the procedure to perform a final assessment that the correct
patient, site, positioning, and procedure are identified and, as applicable, all relevant information and
55
necessary equipment are available.

o Open the packaging of the 3-mL syringe and 25G needle and hand it to the practitioner using sterile
technique.

o Disinfect the top of the lidocaine vial with an alcohol pad, and allow it to dry. Invert the vial and turn the
vial toward the practitioner so that he can visualize the fluid. The practitioner then fills the 3-mL syringe and
injects the anesthetic into the site (as shown).
 o Using sterile technique, hand the practitioner the ultrasound device with the sterile probe cover. Apply
sterile ultrasound gel. The practitioner locates the vessel using the device to reduce the risk of insertion-
related complications.8 11 35 56

o Open the catheter package and inspect the device to make sure that its integrity is intact. Follow the
manufacturer's instructions for use for preparing the catheter for insertion. Flush the catheter with
preservative-freenormalsalinesolution.3 35

o Handthecathetertothepractitionerusingsteriletechnique.Thepractitionertheninsertsthecatheter. 3 35 The
57
practitioner may use electrocardiographic (ECG) guided technology to detect desired tip location.

o Monitor the patient's respiratory rate, heart rate, and oxygen saturation level during the procedure. Observe
37
the cardiac monitor for arrhythmias while the practitioner advances the guide wire and catheter.

o After the catheter is inserted and advanced to the desired tip location, the practitioner aspirates each lumen
forbloodreturn

o Flushthecatheterwithpreservative-freenormalsalinesolution,observingforcomplications. 3 35Clampthe catheter.

o Using sterile technique, flush the needleless connector with preservative-free normal saline solution. Attach
theprimedsterileneedlelessconnectorstothecatheterlumens. 3 35

The practitioner secures the catheter with an engineered stabilization device (as shown), if available, 58 to reduce
vascular access device motion. Device motion increases the risk of unintentional catheter dislodgment and
complications requiring premature catheter removal. 58 Whenever possible, sutures should be avoided because
they're associated with an increased risk of needlestick injury and support the growth of biofilm, which increases the
risk of catheter-related bloodstream infection. 58
o Apply a sterile transparent semipermeable dressing (as shown). 89
Expect some serosanguineous drainage
60
during the first 24 hours.

o Label the dressing with the date of the procedure or the date when dressing change is required, as directed
60
by your facility.

o Place the patient in a comfortable position and reassess his status.

o If insertion wasn't guided by ECG, make sure correct catheter tip location was confirmed by chest X-ray
before administering medications or administering IV therapy, if ordered. The catheter tip should be located
11
in the lower one third of superior vena cava or cavoatrial junction.

o Trace the tubing from the patient to its point of origin to make sure that you're connecting the tubing to the
properport.21 61 62

o Attach the primed IV administration set. Alternately, lock the device if ordered. (See the "Central venous
access catheter flushing and locking" procedure.)

o Route the tubing in a standardized direction if the patient has other tubing and catheters that have different
61
purposes. Label the tubing at the distal (near the patient connection) and proximal (near the source
container)endstoreducetheriskofmisconnectionifmultipleIVlineswillbeused. 61 62

o Verify the electronic infusion device settings. Unclamp the catheter and administer the IV solution as
ordered. Make sure that the electronic infusion device alarm limits are set according to the patient's current
conditionandthatthealarmsareturnedon,functioningproperly,andaudibletostaff.38 39 40
 o Place a disinfectant-containing end cap, if available at your facility, on the remaining needleless connectors
to reducetheriskofvascularcatheter–associatedinfection. 1 63

o Disposeofusedsuppliesinappropriatereceptacles. 50 53

o Return the bed to the lowest position to prevent falls and maintain patient safety. 64

o Removeanddiscardyourglovesandotherpersonalprotectiveequipment. 50 51 53 Performhandhygiene.13 14 15 16
18 19 20

o Documenttheprocedure.65 66 67 68 69

Complications

Complications can occur at any time during infusion therapy. Traumatic complications such as pneumothorax typically
occur on catheter insertion, but might not be noticed until after the procedure is completed. Systemic complications
such as sepsis typically occur later during infusion therapy. Other complications include phlebitis (especially in
peripheral central venous therapy), thrombus formation, and air embolism.

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60. Standard 41. Vascular access device (VAD) assessment, care and dressing changes. Infusion therapy
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61. Standard 57. Parenteral medication and solution administration. Infusion therapy standards of practice.
(2016). Journal of Infusion Nursing, 39, S125–S127.(Level VII)

62. The Joint Commission. (2014). "Sentinel event alert: Managing risk during transition to new ISO tubing
connector standards" [Online]. Accessed April 2017 via the Web at
http://www.jointcommission.org/assets/1/6/SEA_53_Connectors_8_19_14_final.pdf (Level VII)

63. Standard 34. Needleless connectors. Infusion therapy standards of practice. (2016). Journal of Infusion
Nursing, 39, S68–S70. (Level VII)

64. Ganz, D. A., et al. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. Accessed April
2017 via the Web at https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf (Level VII)

65. The Joint Commission. (2017). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)

66. Standard 10. Documentation in the medical record. Infusion therapy standards of practice. (2016). Journal
of Infusion Nursing, 39, S28–S30. (Level VII)

67. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2015). Condition
of participation: Medical record services. 42 C.F.R. § 482.24.

68. Accreditation Association for Hospitals and Health Systems. (2017). Standard 10.00.03. Healthcare Facilities
Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation
Association for Hospitals and Health Systems. (Level VII)

69. DNV GL-Healthcare USA, Inc. (2014). MR.2.SR.1. NIAHO® accreditation requirements: Interpretive
guidelines & surveyor guidance (version 11). Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
70. Standard 49. Infection. Infusion therapy standards of practice. (2016). Journal of Infusion Nursing, 39,
S106–S108. (Level VII)

71. Standard 50. Air embolism. Infusion therapy standards of practice. (2016). Journal of Infusion Nursing, 39,
S108–S109. (Level VII)

72. Standard 42. Administration set change. Infusion therapy standards of practice. (2016). Journal of Infusion
Nursing, 39, S84–S85. (Level VII)

73. Standard 36. Add-on devices. Infusion therapy standards of practice. (2016). Journal of Infusion Nursing,
39, S71–S72. (Level VII)

74. Standard 52. Central venous access device (CAVD)-associated venous thrombosis. Infusion therapy
standards of practice. (2016). Journal of Infusion Nursing, 39, S112–S114. (Level VII)